Claim Form
Legal Form Number | 402(a)(2) |
Section | Office of Congressional Workplace Rights (United States) |
OCWR ADR Form 1
Page 1
Office of Congressional Workplace Rights
John Adams Building, 110 Second Street SE, Room LA-200 | Washington, DC 20540-1999 | (202) 724-9250 (O) | ocwr.gov
Revised June 2024
Office of Congressional Workplace Rights
Administrative Dispute Resolution (ADR) Claim Form
Instructions on how to complete this claim form and how to obtain help are provided at the end of this form.
Section A: Information about you and the employing office
1. Your full legal name: Last: _ First: _
2. Preferred mailing address: _____________________________________________________________________
City: State: ______________ Zip code: ________________
3. Preferred phone number: ___________________________
4. Preferred email: ___________________________________
5. Legislative branch employing office that this claim is filed against:
__________________________________________________________________ _________________________
6. Your employment status: □ applicant □ curren t employee □ unpaid staff
7. If this claim is filed against the Library of Congress, have you filed a formal complaint with the Library’s Office of
Equal Employment Opportunity and Diversity Programs concerning th e same issues that are raised in this claim
form? □ Yes □ No □ My claim is not filed against the Library of Congress
If yes, indicate the date that you filed the formal complaint: __________________ ________________________
8. Is this claim form intended to replace or amend a claim form that you have already filed with OCWR?
□ Yes □ No
If yes, include the case name, case number, and date filed:
Section B: Information about your claim
__________________________________________________________________________ _________________
□ former employee
____________________
__________________ Middle: ___________________ __________________
9. Date(s) or date range that the alleged violation(s) of the Congressional Accountability Ac t (CAA) occurred.
IMPORTANT: Please list the most recent date first.
__________________________________________________________________________ ________________________
10. Check all that you believe apply to your claim:
(a) Unlawful Discrimination:
(i) I have been unfairly treated, at least in part, because of my:
□ Race or color (ethnicity)
□ National origin
□ Religion or religious beliefs
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